Biomedical subjects
Publications and source records attributed to J Patnick.
Data on stage, grade and morphology of 12,761 colorectal cancers registered between 1995 and 2003 by Oxford Cancer Registry are reviewed. Dukes stage is recorded for 81% of colon cancers and for 69% of rectal cancers. Incomplete registry data and changing recording practices may affect future evaluation of bowel cancer screening.
BACKGROUND: This article presents the results and observed effects of the UK National Health Service Breast Screening Programme (NHSBSP) external quality assurance scheme in breast histopathology. AIMS/METHODS: The major objectives were to monitor and improve the consistency of diagnoses made by pathologists and the quality of prognostic information in pathology reports. The scheme is based on a twice yearly circulation of 12 cases to over 600 registered participants. The level of agreement was generally measured using kappa statistics. RESULTS: Four main situations were encountered with respect to diagnostic consistency, namely: (1) where consistency is naturally very high-this included diagnosing in situ and invasive carcinomas (and certain distinctive subtypes) and uncomplicated benign lesions; (2) where the level of consistency was low but could be improved by making guidelines more detailed and explicit-this included histological grading; (3) where consistency could be improved but only by changing the system of classification-this included classification of ductal carcinoma in situ; and (4) where no improvement in consistency could be achieved-this included diagnosing atypical hyperplasia and reporting vascular invasion. Size measurements were more consistent for invasive than in situ carcinomas. Even in cases where there is a high level of agreement on tumour size, a few widely outlying measurements were encountered, for which no explanation is readily forthcoming. CONCLUSIONS: These results broadly confirm the robustness of the systems of breast disease diagnosis and classification adopted by the NHSBSP, and also identify areas where improvement or new approaches are required.
BACKGROUND: The original role of the National Health Service breast screening programme (pathology) external quality assessment (EQA) scheme was educational; it aimed to raise standards, reinforce use of common terminology, and assess the consistency of pathology reporting of breast disease in the UK. AIMS/METHODS: To examine the performance (scores) of pathologists participating in the scheme in recent years. The scheme has evolved to help identify poor performers, reliant upon setting an acceptable cutpoint. Therefore, the effects of different cutpoint strategies were evaluated and implications discussed. RESULTS/CONCLUSIONS: Pathologists who joined the scheme improved over time, particularly those who did less well initially. There was no obvious association between performance and the number of breast cancer cases reported each year. This is not unexpected because the EQA does not measure expertise, but was established to demonstrate a common level of performance (conformity to consensus) for routine cases, rather than the ability to diagnose unusual/difficult cases. A new method of establishing cutpoints using interquartile ranges is proposed. The findings also suggest that EQA can alter a pathologist's practice: those who leave the scheme (for whatever reason) have, on average, marginally lower scores. Consequently, with the cutpoint methodology currently used (which is common to several EQA schemes) there is the potential for the cutpoint to drift upwards. In future, individuals previously deemed competent could subsequently be erroneously labelled as poor performers. Due consideration should be given to this issue with future development of schemes.
AIM: To assess the effect on cancer detection and recall rates of changing from one to two views for incident (subsequent) screens. METHODS: Controlled, comparative, observational study of programmes in NHS breast screening programme in England. SUBJECTS: women aged 50-64 years were screened by the NHSBSP between 1 April 2001 and 31 March 2003. RESULTS: The effect of changing to two-view mammography was a 20% increase in overall incident screen cancer detection rate, with the biggest effect seen for small (<15 mm) invasive cancers. This increased detection rate was achieved with an 11% drop-in recall rate. CONCLUSION: The introduction of two-view mammography for incident screens has resulted in considerable improvements in overall NHS breast screening performance.
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Colorectal cancer is a common cancer and common cause of death. The mortality rate from colorectal cancer can be reduced by identification and removal of cancer precursors, adenomas, or by detection of cancer at an earlier stage. Pilot screening programmes have demonstrated decreased colorectal cancer mortality; as a result many countries are developing colorectal cancer screening programmes. The most common modalities being evaluated are faecal occult blood testing, flexible sigmoidoscopy and colonoscopy. Implementation of screening tests has been hampered by cost, invasiveness, availability of resources and patient acceptance. New technologies such at computed tomographic colonography and stool screening for molecular markers of neoplasia are in development as potential minimally invasive tools. This review considers who should be screened, which test to use and how often to screen.
In 2003, the National Health Service Cervical Screening Programme (NHSCSP) announced that its screening interval would be reduced to 3 years in women aged 25-49 and fixed at 5 years in those aged 50-64, and that women under 25 years will no longer be invited for screening. In order to assess these and possible further changes to cervical screening practice in the UK, we constructed a mathematical model of cervical HPV infection, cervical intraepithelial neoplasia and invasive cervical cancer, and of UK age-specific screening coverage rates, screening intervals and treatment efficacy. The predicted cumulative lifetime incidence of invasive cervical cancer in the UK is 1.70% in the absence of screening and 0.77% with pre-2003 screening practice. A reduction in lifetime incidence to 0.63% is predicted following the implementation of the 2003 NHSCSP recommendations, which represents a 63% reduction compared to incidence rates in the UK population if it were unscreened. The model suggests that, after the implementation of the 2003 recommendations, increasing the sensitivity of the screening test regime from its current average value of 56 to 90% would further reduce the cumulative lifetime incidence of invasive cervical cancer to 0.46%. Alternatively, extending screening to women aged 65-79 years would further reduce the lifetime incidence to 0.56%. Screening women aged 20-25 years would have minimal impact, with the cumulative lifetime incidence decreasing from 0.63 to 0.61%. In conclusion, the study supports the 2003 recommendations for changes to cervical screening intervals.
BACKGROUND: The National Health Service Breast Screening Programme (NHSBSP) is an example of a nationally coordinated quality assurance programme in which all the professional groups involved participate. METHODS: Surgeons, radiologists and pathologists defined the clinical outcome measures against which they would subsequently be audited. The NHSBSP and the Association of Breast Surgery at BASO are jointly responsible for coordinating an annual audit of all surgical activities undertaken within the NHSBSP. RESULTS: The trends for key outcome measures between 1996 and 2001 are provided. The preoperative diagnosis rate (minimum standard 70 per cent or more) improved from 63 to 87 per cent. This rise was mirrored by an increase in the use of core biopsy in preference to fine-needle cytology. The proportion of patients in whom lymph node status was recorded improved from 81 to 93 per cent. There was no significant change in the number of women treated by low case-load surgeons and waiting times for surgery increased through the study interval. CONCLUSION: The BASO-NHSBSP Breast Audit has recorded major changes in clinical practice over 5 years. A key feature has been the dissemination of good practice through feedback of the results at local and national level.
We compared short-term indicators for service mammography screening in Europe. Data were available from 17 programmes, although not all programmes provided a comprehensive reporting. More than 90% of the target population had been screened within the last 3 years in the WE trial, whereas only two-thirds of women in England and Copenhagen had been screened within the last 3 years, which will delay or reduce the effect of screening compared with the trial. Participation was highest in sparsely populated areas. Detection rates at first screen reached three times the baseline in Copenhagen, the Netherlands and North-West England. The clinical characteristics of screen-detected cases were badly reported. Given their importance for the long-term effect of screening, further data are warranted. Sensitivity and specificity could be measured only indirectly; they showed, however, considerable variation between programmes. Fyn, Florence and Stockholm had succeeded in combining high specificity with high sensitivity. With different recall policies, different proportions of women will experience a false-positive test; expected numbers after three screens were 14%, 10% and 1%, for England, Copenhagen and the Netherlands, respectively. Based on the observed wide variation in short-term indicators, a similar wide variation is expected in the effect of screening on breast cancer mortality.
In 2000 the European Commission Advisory Committee on Cancer Prevention published a position paper on cancer screening with recommendations. This followed working party deliberations in 1998 and conference discussion in 1999. Scientific advances, particularly in knowledge about the relationship of HPV and cervical cancer and political developments with the enlargement of the European Union, mean that the position paper and recommendations may shortly need revising in the light of changed circumstances.
Routine programme data and specially designed surveys from 3 demonstration sites were analysed to determine the implications of extending the NHS Breast Screening Programme (NHSBSP), to include routine invitations for women up to 69 years. All women aged 65-69 and registered with GPs in these areas received routine invitations for breast screening along with those aged 50-64. Overall uptake was 71% in women aged 65-69 compared with 78% in younger women, but was > or = 90% in both groups who had previously attended within 5 years. Recall rates were lower for older women, but with a higher positive predictive value for cancer. The percentages of invasive cancer in different prognostic categories were similar in the 2 age groups. Older women took no longer to screen than younger women. The costs per woman invited or per woman screened were also similar to those for women aged 50-64, whilst the cost per cancer detected was some 34% lower in older women. Breast screening is as cost effective for women aged 65-69 as for those aged 50-64, with a higher cancer detection rate balancing shorter life expectancy. The proposed extension to the national programme will have considerable workforce implications for the NHSBSP and require additional resources.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Cervical screening in England is provided free of charge by the National Health Service to all women aged 20-64 years. Computerised call and recall was introduced in 1988 and women receive an invitation every 3-5 years. Smears are taken by the local family doctor, by his/her nurse or at community clinics. Approximately 85% of English women have had a smear in the last 5 years. Quality assurance programmes have recently been established for laboratories and colposcopy clinics and lessons have been learned from previous failures of the service. The incidence has fallen from 16 per 100000 in 1986 to 9.3 per 100000 in 1997. Mortality is currently falling by 7% per year.
The objective was the evaluation of the (cost-)effectiveness of cervical cancer screening in the European Union (EU) countries. Data were collected on recommended screening age ranges and intervals, coverage, proportion of non-negative smears and smear use. Estimates reported by representatives of each participating Member State were compared, and used as input for model based on (using the MISCAN simulation model for cancer screening) effectiveness and cost-effectiveness calculations. Differences in coverage from below 50 to 82% resulted in more or less proportional differences in expected percentage life-years lost reduction, almost regardless of differences in 7-50+ smears recommended in a lifetime. Differences in screening intensity (resulting from the recommended number of smears per lifetime and the number of excess smears on top of these recommendations) resulted in more than 2-fold difference in the expected number of smears per percentage life-years lost reduction. (Cost-)effectiveness predictions would have greatly improved if estimates of long-term coverage had also been available. To conclude, estimates for a restricted set of well defined parameters - a few for short and long-term coverage and one for the total number of smears - are quite useful for country-specific (cost-)effectiveness evaluations. The main, and to some extent, unsolvable problem for further improvement of the analysis is the lack of reliable country-specific estimates for the background risk of cervical cancer in women eligible for screening in the near future.
Endocervical cells are not essential for an adequate smear, except where the previous abnormality was seen in endocervical cells. When three consecutive smears are reported as inadequate, the recommendation for colposcopy should be made at the discretion of the pathologist in the light of a review of the relevant slides and the clinical history of the woman concerned. The cellularity of previous sequential smears should not be combined in order to judge the present smear test as negative. There should be no more than three abnormal smears (including borderline) over any 10-year period without a recommendation for colposcopy. At least three negative smears, at least 6 months apart, should be reported before a woman is returned to routine recall following a smear showing mild dyskaryosis or borderline nuclear change. There is no evidence that demonstrates that selective double screening is any more effective in preventing false-negatives than rapid review and this practice cannot therefore be justified. Sensitivity should be based on all abnormalities detected on primary screening rather than on moderate dyskaryosis or worse. Ranges for reporting rates are based on the 10-90th percentiles of the range for laboratories reporting over 10000 screening smears per year in KC61 returns, but apply to all laboratories reporting screening smears.
OBJECTIVE: To present results from the NHS breast screening programme (NHSBSP) from 1994 through to 1999 and to examine the extent to which interim targets are being achieved. METHODS: Data were collated from all screening programmes in the UK on standard statistical returns. Performance of the screening programme was evaluated using calculated targets based on comparison with the Swedish two counties (STC) randomised controlled trial. RESULTS: In the early years of screening (1988-1993), the NHS programme was detecting more DCIS but considerably less invasive cancers than expected, based on the STC trial. Since the screening year 1993/94 (1 April to 31 March) the standardised detection ratio (SDR) measure of the detection of invasive cancers has increased by 36% from 0.83 to 1.13. The SDR has been greater than 1 since 1996197 suggesting that the NHSBSP has only been screening as efficiently as the STC trial since this date. Uptake for screening has been relatively stable over time at approximately 75%. CONCLUSIONS: The NHSBSP has made considerable advances in performance since its inception in 1988 and screening uptake and age standardised invasive cancer detection rates are (by 1999) well in excess of targets. The early years of screening were characterised by good uptake but a low sensitivity for the detection of invasive cancers. It is anticipated that the screening programme will have an increasing impact on breast cancer mortality, particularly in the 55-69 year age group over the coming years.